OMFS-0108: Bilateral reticular white striae with erosive areas

§Chief complaint

Soreness of both cheeks, worse with spicy food, for 6 months

§Medical & dental history

01Hypertension on an ACE inhibitor
02Hypothyroidism on thyroxine
03Several amalgam restorations, none directly adjacent to the worst lesions

§Clinical examination

01Bilateral symmetric lacy white striae on buccal mucosa (Wickham striae)
02Erosive erythematous area 12 mm on the left buccal mucosa
03Gingival desquamation in the lower anterior region
04Skin: violaceous flat-topped papules on the flexor wrist

§ figuresFigures (3)

Oral Lichen Planus — clinical image: Lichen planus-intra oral lesion — Fig. 1Lichen planus-intra oral lesion
“Lichen planus-intra oral lesion” · Syed Wali Peeran · CC BY-SA 4.0 · Wikimedia Commons

Oral Lichen Planus — clinical image: Classic white striations of non-erosive lichen planus in the left buccal mucosa (left cheek) — Fig. 2Classic white striations of non-erosive lichen planus in the left buccal mucosa (left cheek)
“Lichen planus” · Ian Furst · CC BY-SA 4.0 · Wikimedia Commons

Oral Lichen Planus — clinical image: erosive lichen planus -Intra oral lesion — Fig. 3erosive lichen planus -Intra oral lesion
“Erosive lichen planus” · Syed Wali Peeran · CC BY-SA 4.0 · Wikimedia Commons

Verified open-access images only, reproduced for education under their stated licences · no AI-generated or illustrative artwork · Oral Lichen Planus figures pending faculty review.

§Differential diagnosis

Oral lichen planusBilateral symmetric striae plus skin lesions

Lichenoid drug reactionOften unilateral, temporally linked to a drug

Discoid lupus erythematosusRadiating striae with central atrophy, positive serology

Erosive leukoplakiaUnilateral, no striae

§Final diagnosis

Erosive oral lichen planus with cutaneous involvement

Bilateral symmetry plus Wickham striae plus classic wrist papules make this lichen planus rather than a lichenoid reaction, which is typically unilateral and drug- or amalgam-related.

§Investigations

01Incisional biopsy from a non-ulcerated striated area
02Direct immunofluorescence — shaggy fibrinogen at the basement membrane, excludes pemphigoid
03Fasting glucose and thyroid function

§Treatment plan

01Topical clobetasol 0.05 percent in orabase twice daily
02Antifungal prophylaxis during steroid use
03Avoid spicy and acidic triggers; meticulous plaque control
04Photographic monitoring; systemic steroids only for refractory disease

§Histopathology report

Hyperparakeratosis, saw-tooth rete ridges, basal cell liquefactive degeneration and a dense band-like lymphocytic infiltrate at the epithelial-connective tissue interface. Civatte bodies present. No dysplasia.

§Follow-up & outcome

01Symptomatic relief at 3 weeks; erosion healed by 8 weeks
026-monthly review — small but real malignant transformation risk (~1 percent)

§Clinical pearls / learning points

01Biopsy a striated area, not the ulcer floor — the diagnostic interface change is at the edge.
02Desquamative gingivitis is a clinical sign, not a diagnosis: lichen planus, MMP and pemphigus all cause it.
03Any lichen planus lesion that becomes indurated or nodular needs re-biopsy.

§References

Neville BW et al. Oral and Maxillofacial Pathology, 5th ed.

§Related diseases

Oral Lichen Planus

Chronic T-cell mediated mucocutaneous inflammatory disease with characteristic reticular white striae and, in erosive forms, painful ulcerations. Considered an oral potentially malignant disorder.

Leukoplakia

Predominantly white lesion of oral mucosa that cannot be characterised as any other definable lesion. A potentially malignant disorder.

§Similar cases

OMFS-0106

Homogeneous white patch of the buccal mucosa

OMFS-0120

Recurrent bluish swelling of the lower lip in a teenager

OMFS-0127

Bleeding gingival mass in pregnancy